DISPATCHES

Antimicrobial-Resistant Bacteria in
Infected Wounds, Ghana, 20141

Hauke Janssen,2 Iryna Janssen,2 Paul Cooper, During March–July 2014, we conducted a prospective
Clemens Kainyah, Theresia Pellio, study at St. Martin de Porres Hospital, performing bacte-
Michael Quintel, Mathieu Monnheimer, riologic investigations of infected wounds of inpatients and
Uwe Groß, Marco H. Schulze outpatients during routine working hours (Monday–Friday,
8 am–4 pm). The hospital administration (the local ethics
Wound infections are an emerging medical problem world- review panel) authorized the study. Patients from whom
wide, frequently neglected in under-resourced countries.
wound swab samples were investigated provided consent
Bacterial culture and antimicrobial drug resistance testing
to be included in the study.
of infected wounds in patients in a rural hospital in Ghana
identified no methicillin-resistant Staphylococcus aureus Medical doctors diagnosed wound infections clini-
or carbapenem-resistant Enterobacteriaceae but identified cally, according to the classic signs of inflammation.
high combined resistance of Enterobacteriaceae against After wounds were carefully cleaned with sterile gauze
third-generation cephalosporins and fluoroquinolones. moistened with a sterile solution of 0.9% sodium chlo-
ride, samples were collected from the wound ground and
edge on sterile cotton swabs and immediately transported
B acteriologic investigation of clinical specimens is an
essential tool for active surveillance of antimicrobial
drug resistance. Knowledge of causative bacterial species
to the bacteriology laboratory in Amies transport medi-
um (Copan, Brescia, Italy). The samples were inoculated
onto MacConkey agar and 7% sheep blood agar (Tulip
and their resistance profile enables targeted antimicrobial Diagnostics, Goa, India) and thereafter incubated aerobi-
therapy, limits ineffective antimicrobial therapy, and avoids cally at 35°C. Both plates were read after 24 and 48 hours.
in part unnecessary antimicrobial pressure to noninvolved Gram staining was performed to ensure wound speci-
bacterial pathogens (1). Available antimicrobial resistance men quality and to check for bacteria, neutrophils, and
data will sensitize clinicians and policy makers and are a epithelial cells.
prerequisite for updating national treatment guidelines Bacterial isolates were initially identified (to genus
(1,2). These data contribute to prevention and control of level) by colony morphology, Gram staining, catalase reac-
antimicrobial drug resistance (1). tion, oxidase reaction, coagulase reaction, indole reaction,
Wound infections are an emerging medical problem and growth on Kligler iron agar, as described by Chees-
worldwide; the economic burden and morbidity and mortal- brough (6). Bacterial isolates were stored in microbanks
ity rates are huge (3,4). Because of the frequent polymicro- at –20°C. Species identification was completed (to species
bial nature of infected wounds, bacteriologic investigations level) at the Institute for Medical Microbiology in Goet-
are demanding and frequently neglected in sub-Saharan tingen, Germany, by using MALDI Biotyper 3.0 (Bruker
Africa countries (5). Daltonics, Bremen, Germany).
According to locally available resources, antimicrobial
The Study resistance testing was performed through disk diffusion,
Since 2000, the Institute for Medical Microbiology of which guided the treatment of the wound infections. Antimi-
the University Medical Center Goettingen, Goettingen, crobial resistance testing was repeated with VITEK 2 (bio-
Germany, has assisted the running of the bacteriology labo- Mérieux, Marcy-l’Étoile, France) at the Institute for Medical
ratory in St. Martin de Porres Hospital in Eikwe, Ghana Microbiology by using AST-P632, AST-P586, AST-N214,
(2). Eikwe is a rural coastal village in the Western Region and AST-N248 cards with respect to bacterial species
of Ghana; its mission hospital has an admission capacity of and according to the breakpoint tables for interpretation
≈200 beds and serves ≈380,000 persons.
1
Preliminary results from this study were presented at the
Author affiliations: University Medical Center Goettingen,
Annual Meeting of the German Society of Tropical Medicine and
Goettingen, Germany (H. Janssen, I. Janssen, M. Quintel, International Health; October 7–8, 2016; Bonn, Germany; and at
M. Monnheimer, U. Groß, M.H. Schulze); St. Martin de Porres the 69th Annual Meeting of the German Society for Hygiene and
Hospital, Eikwe, Ghana (P. Cooper, C. Kainyah, T. Pellio) Microbiology; March 5–8, 2017; Wuerzburg, Germany.

DOI: https://doi.org/10.3201/eid2405.171506
2
These authors contributed equally to this article.

916 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 24, No. 5, May 2018
 Antimicrobial-Resistant Bacteria in Wounds

of MICs in EUCAST version 4.0 (7). Quality control was The spectrum of isolated bacteria is comparable to that
performed with the reference strains Pseudomonas aeru- reported by other studies from sub-Saharan Africa coun-
ginosa ATCC 27853, Escherichia coli ATCC 25922, and tries, such as Nigeria (9), Tanzania (3), and Rwanda (10).
Staphylococcus aureus ATCC 29213. Frequently, studies describe detected pathogens at the ge-
Of the 67 wound swab samples, 39 (58.2%) were from nus level only (3,10). Concerning the proportion of gram-
female patients. The mean age of the 67 patients was 40.1 positive to gram-negative pathogens, we isolated slightly
± 20.8 years (range 1–90 years, median 39 years). Of the 67 more gram-positive pathogens than others (3,9–11).
samples, collection sites were upper extremity for 4 (6.0%), One of the most common bacteria found in wound
trunk/head for 15 (22.4%), lower extremity for 39 (58.2%), infections is S. aureus (3,5,10–12), which was most fre-
and laparotomy site for 9 (13.4%) (online Technical Ap- quently identified in our study (online Technical Appendix
pendix, https://wwwnc.cdc.gov/EID/article/24/5/17-1506- Table 2); however, we detected no methicillin-resistant S.
Techapp1.pdf). A hospital-acquired wound infection was aureus (MRSA). In contrast, studies from urban areas in
diagnosed for 21 (31.3%) patients. sub-Saharan Africa countries found MRSA rates of >80%
All investigated wound swab samples grew bacterial (10,12). Urban areas are centers of specialized healthcare,
pathogens. Overall, 32 species of bacteria were isolated; where many patients who may already have a long medi-
median was 3 (range 1–7) species/specimen. Of the 189 cal history are referred. Such referrals predispose urban
isolated species, 72 (38.1%) were Enterobacteriaceae, 69 patients, staff, and others to more MRSA colonization and
(36.5%) were gram positive, and 48 (25.4%) were nonfer- infection than experienced by those in rural areas (13). The
menters (online Technical Appendix Table 2). Of the 67 hospital in Eikwe is a general hospital; the villagers are
samples, infection was monomicrobial in 17 (25.4%) and mainly fishermen, and there are no big animal farms in the
polymicrobial in 50 (74.6%). The most frequently detected area. Predisposition to MRSA in this area may be low.
bacterium in monomicrobial and polymicrobial infections We found no carbapenem resistance in Enterobacte-
was S. aureus. The predominant bacteria in polymicrobial riaceae (Table 1). Of great concern were the high rates of
infections were Enterobacteriaceae and nonfermenters resistance of E. coli, Klebsiella pneumoniae, and Entero-
(online Technical Appendix Table 3). Results of VITEK bacter cloacae complex against third-generation cepha-
2 antimicrobial resistance testing of the most frequently losporins, fluoroquinolones, or both (Table 2), as have
found bacterial species are shown in Table 1. been found in other studies from urban areas (3,5,10). The

Table 1. Percentages of antimicrobial drug resistance in selected bacterial species in wound infections, Ghana, 2014*
% Resistant
Enterococcus Proteus Klebsiella Enterobacter Pseudomonas Acinetobacter
Staphylococcus faecalis, mirabilis, Escherichia pneumoniae, cloacae aeruginosa, baumannii
Drug aureus, n = 31 n = 21 n = 20 coli, n = 19 n = 13 complex, n = 10 n = 20 complex, n = 8
PEN 93.5
AMP 0 70.0 94.7 100 100
OXA 0
SAM 0 45.0 82.2 69.2 100
TZP 0 10.5 46.2 30.0 10.0
CXM 5.0 57.9 46.2 80.0
CTX 5.0 47.4 46.2 40.0
CAZ 5.0 47.4 46.2 40.0 5.0 37.5†
IPM 0 0
MEM 0 0 0 0 5.0 0
ERY 3.2 100
CLI 3.2 100
TET 67.7 100
GEN 3.2 15.0 46.2 46.2 40.0 10.0 62.5
AMI 0 0
CIP 20.0 46.2 46.2 30.0 15.0 37.5
LVX 0
SXT 32.3 100 75.0 69.2 69.2 50.0
FOF 0
RIF 0
VAN 0 0
*Antimicrobial susceptibility testing was performed with VITEK 2 (bioMérieux, Marcy-l'Étoile, France) according to the EUCAST breakpoint tables for
interpretation of MICs, version 4.0, 2014 (7). Blank cells indicate no testing performed. AMI, amikacin; AMP, ampicillin; CAZ, ceftazidime; CIP,
ciprofloxacin; CLI, clindamycin; CTX, cefotaxime; CXM, cefuroxime; ERY, erythromycin; FOF, fosfomycin; GEN, gentamicin; IPM, imipenem; LVX,
levofloxacin; MEM, meropenem; OXA, oxacillin; PEN, penicillin; RIF, rifampin; SAM, ampicillin/sulbactam; SXT, trimethoprim/sulfamethoxazole; TET,
tetracycline; TZP, piperacillin/tazobactam; VAN, vancomycin.
†The interpretation of the CAZ MIC for A. baumannii complex followed the recommendations of the Clinical and Laboratory Standards Institute
performance standards for antimicrobial susceptibility testing (8).

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 24, No. 5, May 2018 917
DISPATCHES

Table 2. Ratio of percentages of antimicrobial drug resistance against third-generation cephalosporin CTX and the fluoroquinolone
CIP in selected Enterobacteriaceae isolated from wound infections, Ghana, 2014*
% Resistant
Klebsiella pneumoniae, Enterobacter cloacae
Drug resistance Proteus mirabilis, n = 20 Eshcerichia coli, n = 19 n = 13 complex, n = 10
CTX-S + CIP-S 80.0 42.1 53.8 60.0
CTX-S + CIP-R 15.0 10.5 ND ND
CTX-R + CIP-S ND 5.3 ND 10.0
CTX-R + CIP-R 5.0 42.1 46.2 30.0
*Antimicrobial susceptibility testing was performed by using VITEK 2 (bioMérieux, Marcy-l'Étoile, France) according to the EUCAST breakpoint tables for
interpretation of MICs, version 4.0, 2014 (7). CIP, ciprofloxacin; CTX, cefotaxime; ND, not detected; R, resistant; S, susceptible.

indiscriminate use of antimicrobial drugs contributes to and the staff from the Institute for Medical Microbiology of the
this factor (14). Officially, selling antibiotics without pre- University Medical Center Goettingen for their commitment to
scription is not allowed in Ghana; however, almost every perform the study.
oral antimicrobial drug is available over the counter with-
out any prescription. Eikwe is no exception, although the
About the Author
spectrum of available antimicrobial drugs may be smaller
Dr. Janssen is an anesthesiologist who during the study worked
there than in cities. Development of antimicrobial drug
as a volunteer at St. Martin de Porres Hospital. He supported the
resistance may also be enhanced by circulation of coun-
medical personnel in the operating theater and trained them in
terfeit drugs (15).
anesthesiology, resuscitation, and general medicine.
Resistance of E. coli and K. pneumoniae against third-
generation cephalosporins probably occurs through pro-
duction of extended spectrum β-lactamase; in E. cloacae References
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918 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 24, No. 5, May 2018
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